Vigorous Exercise in Patients With Hypertrophic Cardiomyopathy
Authors: Rachel Lampert, Michael J. Ackerman, Bradley S. Marino, Matthew Burg, Barbara Ainsworth, Lisa Salberg, Maria Teresa Tome Esteban, Carolyn Y. Ho, Roselle Abraham, Seshadri Balaji, Cheryl Barth, Charles I. Berul, Martijn Bos, David Cannom, Lubna Choudhury, Maryann Concannon, Robert Cooper, Richard J. Czosek, Anne M. Dubin, James Dziura, Benjamin Eidem, Michael S. Emery, N. A. Mark Estes, Susan P. Etheridge, Jeffrey B. Geske, Belinda Gray, Kevin Hall, Kimberly G. Harmon, Cynthia A. James, Ashwin K. Lal, Ian H. Law, Fangyong Li, Mark S. Link, William J. McKenna, Silvana Molossi, Brian Olshansky, Steven R. Ommen, Elizabeth V. Saarel, Sara Saberi, Laura Simone, Gordon Tomaselli, James S. Ware, Douglas P. Zipes, Sharlene M. Day, Dominic Abrahms, Euan Ashley, Peter Aziz, Anjan Batra, Marina Cerrone, Steven Colan, Christopher Erickson, Ahmad Ferhaan, Michael J. Gollob, Christopher Johnsrude, Prince Kannankeril, Ronald Kanter, Walter Li, Ahmad Masri, Ann Murphy, Deipanjan Nandi, Marco Perez, James Perry, Eric Popjes, Roopa Rao, David Rosenthal, Shubhayan Sanatani, Chris Semsarian, Maully Shah, Jonathan Skinner, Jill Tardif, Jeffrey Towbin, Aslan Turer, Gregory Webster, Omar Wever-Pinzon, Timothy Wong
Journal: JAMA Cardiology (2023)

Importance Whether vigorous intensity exercise is associated with an increase in risk of ventricular arrhythmias in individuals with hypertrophic cardiomyopathy (HCM) is unknown. Objective To determine whether engagement in vigorous exercise is associated with increased risk for ventricular arrhythmias and/or mortality in individuals with HCM. The a priori hypothesis was that participants engaging in vigorous activity were not more likely to have an arrhythmic event or die than those who reported nonvigorous activity. Design, Setting, and Participants This was an investigator-initiated, prospective cohort study. Participants were enrolled from May 18, 2015, to April 25, 2019, with completion in February 28, 2022. Participants were categorized according to self-reported levels of physical activity: sedentary, moderate, or vigorous-intensity exercise. This was a multicenter, observational registry with recruitment at 42 high-volume HCM centers in the US and internationally; patients could also self-enroll through the central site. Individuals aged 8 to 60 years diagnosed with HCM or genotype positive without left ventricular hypertrophy (phenotype negative) without conditions precluding exercise were enrolled. Exposures Amount and intensity of physical activity. Main Outcomes and Measures The primary prespecified composite end point included death, resuscitated sudden cardiac arrest, arrhythmic syncope, and appropriate shock from an implantable cardioverter defibrillator. All outcome events were adjudicated by an events committee blinded to the patient’s exercise category. Results Among the 1660 total participants (mean [SD] age, 39 [15] years; 996 male [60%]), 252 (15%) were classified as sedentary, and 709 (43%) participated in moderate exercise. Among the 699 individuals (42%) who participated in vigorous-intensity exercise, 259 (37%) participated competitively. A total of 77 individuals (4.6%) reached the composite end point. These individuals included 44 (4.6%) of those classified as nonvigorous and 33 (4.7%) of those classified as vigorous, with corresponding rates of 15.3 and 15.9 per 1000 person-years, respectively. In multivariate Cox regression analysis of the primary composite end point, individuals engaging in vigorous exercise did not experience a higher rate of events compared with the nonvigorous group with an adjusted hazard ratio of 1.01. The upper 95% 1-sided confidence level was 1.48, which was below the prespecified boundary of 1.5 for noninferiority. Conclusions and Relevance Results of this cohort study suggest that among individuals with HCM or those who are genotype positive/phenotype negative and are treated in experienced centers, those exercising vigorously did not experience a higher rate of death or life-threatening arrhythmias than those exercising moderately or those who were sedentary. These data may inform discussion between the patient and their expert clinician around exercise participation.